Right Versus Left Distal Axillary Vein Cannulation

Right Versus Left Ultrasound-Guided Distal Axillary Vein Cannulation : A Prospective Randomized Study

Central venous cannulation is an essential procedure in the anaesthetic and critical care practice. Ultrasound has revolutionized the practice favoring the internal jugular cannulation to the other sites .Subcalvian vein cannulation has fallen out of favor mainly due to the difficult visualization with the ultrasound, especially in obese patients and the inevitable position of the clavicle acting as a bony obstacle , in addition to the anatomical position in vicinity to the pleura which might raise the risk of pneumothorax . Indeed the subclavian vein cannulation is more comfortable and tolerated by the patient especially those requiring long term intravenous therapy, with less rates of infection and thrombosis. This mandated the development of a safer and efficient technique for the cannulation empowered by the ultrasound technology.

The infracalvicular approach or the proximal axillary vein cannulation has been described but is not popular. It provides a potentially safer and successful technique with less complication both in "experienced" and "less experienced"operators . All the patients will receive general anaesthesia with laryngeal mask insertion . Careful sterilization of the surgical site and strict aseptic techniques for the handling of the ultrasound probe will be pursued

Study Overview

• Status: Recruiting
• Conditions: Infraclavicular Vein Cannulation; Venous Cannulation
• Intervention / Treatment: Procedure: Ultrasound guided right infraclavicular approach of subclavian vein cannulation; Procedure: Ultrasound guided left infraclavicular approach of subclavian vein cannulation

Detailed Description

All patients will be in supine position, with the arm abducted to 45 degrees , the angle of the arm will be adjusted to acquire best image. The probe will be placed in he parasagittal plane in the deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accordingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the axillary vein . The needle will be introduced in real time imaging , in an in-plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging .The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin, Infraclavicular incision will be performed for the port site , the port will be secured in a dissected pocket right above the pectoralis major muscle .Flush back will be confirmed from the port .The incision will be closed in layers .The final position of the catheter tip will be confirmed using fluoroscopic guidance. In case of difficult visualization or failure of cannulation of one side , the subclavian vein of the contralateral side will be scanned and cannulated . The internal jugular vein will be the cannulated instead if any further difficulties were encountered .

• Study Type: Interventional
• Enrollment (Estimated): 80
• Phase: Not Applicable

Contacts and Locations

• Study Contact: Name: Engi y Hashem, MD; Phone Number: 0201223372319; Email: engi.hashem@alex-mri.edu.eg
• Study Contact Backup: Name: Wessam Z ElAmrawy, MD; Phone Number: 0201280998606; Email: Wesam.amrawy@alex.edu.eg

Study Locations

• Egypt
  • Alexandria Governorate
    • Alexandria, Alexandria Governorate, Egypt, 21561
      • Recruiting
      • Medical Research Institute
      • Contact: khaled Matarawy, MD; Phone Number: 02034282331; Email: mri-dean@alexu.edu.eg

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

.Patients requiring porta Cath insertion.

Exclusion Criteria:

• Abnormalities in the platelet count or coagulation
• Thrombosis of the target vein
• Soft tissue infection of the overlying area
• Fracture of the clavicle or proximal ribs
• Patients with pacemakers or defibrillators
• Malignant superior vena cava syndrome
• Gross obesity
• History of prior catheterization of the subclavian vein
• Patient refusal to participate in the study.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Other: Right subclavian vein cannulation; All patients will be in supine position, with the right arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image. The probe will be placed in he parasagittal plane in the deltopectoral groove of the right side , medial to the coracoid process . The image will be optimized for the best image of the right axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the right axillary vein . The needle will be introduced in real time imaging , in an in plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging. The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.	Procedure: Ultrasound guided right infraclavicular approach of subclavian vein cannulation; All patients will be in supine position, with the arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image.The probe will be placed in he parasgittal plane in the deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accorgingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the axillary vein . The needle will be introduced in real time imaging , in an inplane technique and blood will be aspirated , the guidewire will be introduced in real time imaging.The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.
Experimental: Left subclavian vein cannulation; All patients will be in supine position, with the left arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image. The probe will be placed in he parasagittal plane in the left deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accordingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the left axillary vein . The needle will be introduced in real time imaging , in an in plane technique and blood will be aspirated , the guidewire will be introduced in real time imaging. The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.	Procedure: Ultrasound guided left infraclavicular approach of subclavian vein cannulation; All patients will be in supine position, with the arm abducted to 45 degrees , the angle of the arm will be increased to 90 degrees to best acquire the image.The probe will be placed in he parasgittal plane in the deltopectoral groove medial to the coracoid process . The image will be optimized regarding the depth , focus and the gain accorgingly for the best image of the axillary artery and vein similar to that acquired when performing an infraclavicular approach for brachial plexus block . The probe will be rotated to obtain a longitudinal image of the axillary vein . The needle will be introduced in real time imaging , in an inplane technique and blood will be aspirated , the guidewire will be introduced in real time imaging.The internal jugular vein will be scanned bilaterally via ultrasonography to exclude malposition of the guidewire and will be reported in case of such. The catheter will be introduced through the sheath and will be tunneled the skin.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of Successful cannulation	Recognition of the catheter in the SVC by fluoroscopy	Directly after the end of the procedure

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rate of malposition identified by the ultrasound	The ultrasound probe will be positioned on the internal jugular vein for the recognition of malposition of the guidewire	Directly after the insertion of the guidewire and the catheter
Complication of the procedures	All the complications will be recognized and reported	Directly at the end of the procedure

Collaborators and Investigators

• Sponsor: Alexandria University
• Investigators: Principal Investigator: Engi Y Hashem, MD, Medical research institute , Alexandria university

Publications and helpful links

General Publications

• Kim YJ, Ma S, Yoon HK, Lee HC, Park HP, Oh H. Supraclavicular versus infraclavicular approach for ultrasound-guided right subclavian venous catheterisation: a randomised controlled non-inferiority trial. Anaesthesia. 2022 Jan;77(1):59-65. doi: 10.1111/anae.15525. Epub 2021 Jul 6.
• Imai E, Watanabe J, Okano H, Yokozuka M. Efficacy and safety of supraclavicular versus infraclavicular approach for subclavian vein catheterisation: An updated systematic review and meta-analysis of randomised controlled trials. Indian J Anaesth. 2023 Jun;67(6):486-496. doi: 10.4103/ija.ija_837_22. Epub 2023 Jun 14.
• Hosur Ravikumar R, Majage S, Prasanna M, Ray BR. Comparison of ultrasound guided supraclavicular subclavian vein versus infraclavicular subclavian/axillary vein catheterization: A systematic review and meta analysis. J Vasc Access. 2025 Mar;26(2):633-640. doi: 10.1177/11297298241239092. Epub 2024 Mar 20.

Study record dates

Study Major Dates

• Study Start (Actual): October 21, 2024
• Primary Completion (Estimated): July 1, 2026
• Study Completion (Estimated): August 1, 2026

Study Registration Dates

• First Submitted: October 10, 2024
• First Submitted That Met QC Criteria: January 5, 2025
• First Posted (Actual): January 7, 2025

Study Record Updates

• Last Update Posted (Actual): June 17, 2026
• Last Update Submitted That Met QC Criteria: June 16, 2026
• Last Verified: June 1, 2026

More Information

Terms related to this study

• Keywords: ultrasound guided; fluroscopy; subclavian vein cannulation; maldirection; infraclavicular approach
• Other Study ID Numbers: Axillary vein cannulation

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO
• IPD Plan Description: unfortunately there is no web site for the publication of results , but whoever is interested in the study can contact the main author

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No